COMMONWEALTH OF MASSACHUSETTS
REDUCED FARE PROGRAM 3/2017
Transportation Access Pass CharlieCard Application
Incomplete Applications Will Not Be Processed or Returned
PART A: To Be Completed by Applicant
Applicant Information: (Please Print)
First time applicant
Renewal
Last Name___________________ First Name _______________ MI____
Address _____________________________________Apt. No.________
City ______________________________ State ________ Zip_________
Phone ____________________________ DOB _____/_____/__________
Emergency Contact Information: Name __________________________
Relationship __________________ Phone _________________________
Disability Information Release Authorization:
I authorize the health care professional completing this application
to release information about my disability to the Massachusetts
Bay Transportation Authority (MBTA).
_________________________________________
Applicant Original Signature
________
Date
Application Submittal: Please return the completed application
to the following address.
No Photocopies or faxes accepted.
MBTA CharlieCard Store, Downtown Crossing Station, Chauncy
Underground Concourse, 7 Chauncy St., Boston, MA 02111
You will receive an Application Status Letter in 6 – 8
weeks
with instructions how to obtain your Reduced Fare
CharlieCard.
When visiting the CharlieCard Store, please present original
documentation and valid Driver’s License or ID with an
expiration date from the Registry of Motor Vehicles or
Passport.
PART B: TAP CharlieCard Eligibility Criteria
Automatically Eligible Applicants (Original Documents ONLY)
Applicants who meet one of the criteria below are automatically
eligible for a Transportation Access Pass CharlieCard. Simply
complete PART A, check off the category below that applies to
you and present the required documentation.
Application may be subject to submission depending upon
documentation presented
Medicare Card Holder/Part A & B or One Care Card: Please
present your Red, White, and Blue Medicare Card or
Commonwealth Care Alliance One Care Card at the time of
visit. (No Photocopies)
Current customer of THE RIDE: RIDE ID #:
____________________.
Veteran with a disability rating 70% or greater: Present
Benefits Summary Letter on Veterans Administration
letterhead, specifying disability rating.
Reduced Fare card holder from MA or Out-of-State:
Present a current reduced fare card from your state or area
with an expiration date.
Client of DMH/Department of Mental Health (including DMH
vendors): Present original letter on agency letterhead, from
authorized DMH representative (or vendor) verifying status as
current client.
Client of DDS/Department of Developmental Services:
Present original letter on agency letterhead, from authorized
DDS representative verifying status as current client.
All Other Applicants
If you do not meet one of the above criteria, complete PART A and
have your licensed health care professional complete PART C of
this application.
IMPORTANT RULES AND CONDITIONS OF USE
Your participation in the Transportation Access Pass CharlieCard Program is
administered in accordance with the MBTA's Privacy Policy. The policy can be
found at www.mbta.com.
Your Transportation Access Pass CharlieCard is subject to inspection or review by
MBTA personnel at any time to ensure use by only the authorized person.
An unauthorized person using your Transportation Access Pass CharlieCard is
subject to criminal/civil penalties under Chapter 161, Section 113A of the MA
General Laws and/or any other applicable MA General Laws. Additionally, you may
be disqualified or suspended from participating in the Transportation Access Pass
CharlieCard program for allowing unauthorized use of your card.
PART C: Health Care Professional
Certification
PART C must be completed by a licensed or certified health care professional, and must
be received by the MBTA within 60 days of the health care professional’s signature.
Please P-R-I-N-T.
Name of Health Care Professional
________________________________________________
Licensure Title
______________________________Specialty__________________________
License Number _______________________ State Issued
____________________________
Business Address
____________________________________________________________
City _________________________State _______ Zip _________Phone
___________________
IMPORTANT PROGRAM NOTE: The MBTA issues the Transportation Access Pass
CharlieCard based on the level of difficulty applicant’s experience, and the extra
planning and effort that may be required, to use public buses/trains/subway due to a
physical, psychiatric, intellectual or sensory disability. The TAP CharlieCard is issued
to applicants with disabilities who find it moderately/severely difficult to wait for a bus,
hear announcements, read visual signs, understand and/or follow directions, board the
correct train, maintain stamina, function well in crowds, walk certain distances to
transfer between transit modes, etc. The TAP CharlieCard IS NOT ISSUED based on
applicant's income level.
1. What is the applicant's disability?
Use Guideline Number(s) from back
page___________________________________________
Specific Diagnosis: (Must be completed by the Health Care Professional)
______________________________________________________________________
______
______________________________________________________________________
______
2. How does the disability cause the applicant difficulty, as described in
"Important Program Note" section above, when traveling on the MBTA?
Please specify: (Must be completed by the Health Care Professional)
______________________________________________________________________
______
______________________________________________________________________
______
3. Expected duration of disability: Please select only one of the two options below:
_________ Conditions with potential for improvement within 1 year
_________ Conditions with no expectation of improvement
4. I certify that the information I have provided above about this MBTA TAP
CharlieCard applicant is correct to the best of my knowledge:
_______________________________________
____________________
Original Signature of Health Care Professional
Date
Guidelines for Health Care Professionals
Please use the categories below to complete Part C Health Care Professional
Certification, Item #1: "What is applicant's disability?"
1. WHEELED MOBILITY DEVICE USERS:
Those who, due to a disability, require the
use of wheeled mobility, e.g. wheelchair,
scooter, etc.
2. SEMI-AMBULATORY DISABILITIES: Those
who, due to a disability, walk with difficulty or
insecurity and may or may not use leg braces,
walker, cane, crutches.
3. SEVERE MUSCULOSKELETAL
4. AMPUTATION OF AN EXTREMITY. Please
CONDITIONS such as muscular dystrophy,
specify which limb(s) are affected.
osteogenesis imperfecta or arthritis where
functional capacity is limited in ability to
perform usual self care and/or vocational and
avocational activities.
5. SEVERE EFFECTS FROM CVA (STROKE):
Eligible conditions include functional motor
deficit affecting any two limbs or ataxia 4
months post cva.
6. SEVERE PULMONARY CONDITIONS
(obstructions/ restrictions) that affect mobility.
Those with PFT outcomes < 50% of predicted
values (FEV1; FVC; %FEV1; FEF25%-75%).
Dyspnea occurs during usual activities of daily
living; climbing a flight of stairs or walking 100
yards; with the slightest exertion; or even at rest.
7. SEVERE CARDIAC CONDITIONS that
result in moderate or marked restriction in
ordinary physical activity; and may cause
fatigue, palpitations, dyspnea or angina pain
when walking one or more level blocks,
climbing a flight of ordinary stairs, or even at
rest. Classifications: Functional III or IV;
Therapeutic C or D.
8. PERSONS REQUIRING KIDNEY DIALYSIS
TREATMENT
10.
HEARING-RELATED DISABILITIES:
Deafness or hearing loss of 90 db or greater
in the 500, 1,000, and 2,000 HZ ranges.
Please specify the degree of response in
each of these ranges.
11.COORDINATION DISABILITIES: Those with a
functional motor deficit in any two limbs or who
experience manifestations that significantly
reduce mobility, coordination and/or perception.
12.
INTELLECTUAL DISABILITY: Those
with I.Q. more than two standard deviations
below the norm. Please specify I.Q.
13.
CEREBRAL PALSY: Please include extent
of difficulty in motor function.
14.
EPILEPSY (CONVULSIVE
DISORDER): Please include severity and
frequency of seizure activity despite
medication.
15.
AUTISM: Please describe nature and
severity of disability.
16.
NEUROLOGICAL DISABILITIES
affecting learning, perceptual and behavioral
functioning. Please include nature of
condition and etiology.
17.
PSYCHIATRIC DISABILITIES: This section
applies to those who have a serious, long-term
mental illness, that:
18.
PROGRESSIVE ILLNESSES that
impact the performance of the applicant's
organic system so the symptoms produced
fall within categories 1 – 17 above.
Please indicate applicable categories above
that best describe impact of illness on
applicant's functional ability to use public
transit buses, subway and trains.
9. VISION IMPAIRMENTS: Those who are legally
blind, whose visual acuity in the better eye, after
correction, is 20/200 or worse or visual field is
contracted. [Applicant will be eligible for MBTA
Blind Access CharlieCard with a current MA
Commission for the Blind Card/Certificate or
other Blindness Certification]
•
•
•
includes a substantial disorder of thought,
memory, perception, or orientation
grossly impairs judgment, behavior, capacity
to recognize reality, or
greatly impacts ability to meet ordinary/
independent life support needs of food,
shelter, clothing, management of finances,
and health care.
Please indicate description and duration of
condition.
For Internal Use Only: Staff initials __________ Date __________
Approved: __________ Auto Renew __________ Denied __________ Incomplete __________